HomeMy WebLinkAbout1687A ti-ORKfRS'COMPENSATION DECIARATION APPLICATION FOR PLUMBING PERMIT ����+" l� �
� I hereby nfhrm rhni I hnve n cendimte oF mnsent!o selt
insure,o�o cer�iFica'e o(Wnrkers'Compensation Insurnnce, �F A177�FV.�OiAI� p �� `G
C�O CP.�ti(iBf�[Ary IFtPlCOI(SP:.3NJO,LOiII.C.� CpUNTV OF LOS ANGELES BUILDING AND SAFE?Y `1
acYN°1+�-�,,,-1�Company � 1 na1 P_�LIhC�. _ .
Cenified copy is hereby fumishPd. Ru�;D•NG/)- 1 1 � �� 1 �
FCYi APPLIC:•NT 70�RL iv��a!Ni CR TYPE) L •
�Cer.Yied conY�s filed wiih ihe coun!y ba�d�ng inspec- ADcvE55 ( �-] lV e
Iion depa��m�nl. hUMBFR FIX7UQE O4ITE.N � FEE \
/�_� � .,�� ��Q� �� ^ LCCALITV
�o�el]—�LLAppl�ca�i 2� �,( W4iERCLOSET 1 0—.4^��
IyEARESi �
CERTIFICATE OF ExEMPTION FROM WORKERS' � AATI{T�g , CRC55 ST. �
COMPENSATION INSURANCE C'h•NEFI� C �
(This�acfion nwd not b�complNad Ii fhs work invalr�d by SHOwEe ,� ;��
Ih� �mdl I�for ona hundred dollon SI00 Or Issi. MA��
P � ) I IAVATORv � —�" ADDRE55�
I cenify thor in rhe performonce o(rhe work for wh�ch�h�s �
pe�m��is issued,I shall not empl�y ony perso�in any manner 1 S�NK C�TV �- �` T 2�.'
so as io become wbjnc��o ihe Workers'Compensouon laws. ��n
' DISHWASfIFR � �CNTRA�iOR�r ,� � � S
Do�e Appl?mnl ` CIOTHESWASu(R -� e,CDRESS
NOiICE TO A7VlICANT: Ii, aNr rnakinq IhiS Canrf�coie of 5`A'IMMIYGPOOIRECCPT04
�mpi�on, you should kxcome cubject �o the Workms' CitY \ 7 r�E
mpensn�ion prov�s�ons o1+he Labor Code,you must fwlh- ��v;N�!hrirqcycr�M. `Je�S\1��f i 1rf: 1'i��'�� R 3-R �
wi�h comply w rh such previs�ons or �his permit sFwl� bo
deemed revoked. �� STA�E ` �.
LICENSED CONTRACTORS DECIARATION ''�'4TfRHEAifR "� _ �, L!CENSE NO. 1 C�nSS �
19 D�SiRICT NO PROCFSSED Bv
I hereby affirm thot I om I�censed under p.ovisions oF CMp+er 9 � c�55v5rEm OU7tET5 � 1 ���
(comr�ancing wiih SeUion 70pp)of Division 3 of�he Bus+ness L`uiiEi50vFR
o�d Pro!ess�ons Code,and my license is in ivll force and eHec1. 5 PER Sv5iEti1 FINAL
/� �7 � VALIDA710N
-Z�-t �-
Litense Nvmber � Lic.Class_.S_.,'�.32_ �ATE n-.
i ` `� O
Y� �,{th S FINAL O
� ControdorQ �1 P.r Da!e.�.� BY u f
I ❑ �
I om e�ampt under$et. O
W� B.6P.C.for this rnnson plan check fee , a.
� �a'^ !n
� PIU.MBING PERMIT ISSU!NG FEf 5 ` Z
I Sig�awrr
�
TOTAL FEE
Plon check oppt�cant
I SINGIF.FAMILY
HO.ME OWYER-BUILDFR DECLARATION Name
�� '�ereby afhrm rFni I�m r.xempl irom the Comm:�or's Lice.ns^ Address
�,��,rtie r��i�..�inp rc^son�Sc�ion 7Q31.5.Business ar,d
� ' ulessions Code): Ciry Tel.No.
I � I,as owner of the oroperiy,will do 7he wo�k nnd tti!t
s�rucrure is nn� imended or effered fer salr. (Snction ► ..� ��r�'�
704d,Business nnd Croiqss�o�s Cede).
CONSTRUCTION IENDING AGENCY , • e e . o�j
I hereby nfiirm iho�ihare is a cens!ructinn lendinq o�r.ncy for
ihe pe�fo�mnnce of the werk(e�whlch ihis permlt�s�ssued � ^ � (}(}.�Q
(Sec.3097,CIv.C.).
^ i i;1.J(;�
Lender's Name 4
0".L�:.-8G
Lender's Address
I cer�Fy ih��I have read�ti�s aFPl�ca��on�nd s'n�?thar thr. ►
nh,ove ir(crmo�ion is to�r�ct.I nqree!o comply wi•h all COunly
ard��a�ces and S�n�r lows re�ulotin�Plumh�n�,�nd hereby
ou�ha�:e rep�esento�i�es of ih�s Coomy to Pnter upon nc�
ebov=�r�ennonr�prr.pe•ty fer�ns;,ecr�on purpo•es.
SEE REVERSE FOR EXPLANATORV LANGUAGE
Q�-1��`�f�
S�g oWr, f ermii•e� Da�e
r.
G
G� � �? c;,
?. � c.
C �1 : U ir 'f' t? �F
c, �` '� 3, �,
� -i
;aa "l. � �• �`' T, J, !. G ?� i�.
i� � '`, �n '7 � 4� , U
?,,� n -� c� N �, =' � '
.,�„ � ' ?'; 1 �,' ''
,�?t ?, y� Z. L� .M1 ��n
11' V �' � \
T \ v�� }U �
Cv v V .
�� � � � ^
_ � ,Sa ` N J �^
- •��,,��: •��
r � 7-
Q'+<n i 1
�`� �' 1 \ \ .`.i
� �
Z ��~ � O
�
�� - . \ C
C� ��
O 1 �:
N •
x.,
? � -
a
(J� .
�
\
\ ` "
u.i
1��
_.� � ` O
` O
��
\ ` �
G r -� .
O p G �' ^
� �, P
N �O � C" C - y' a.
^ o� ° »3 % Nv a � a •
? ���,.� '�" � ° �'=° " cr°.c ° O
� � O A Q 0 '�� G� .^�. O �y C .) ,. � .
. , o �� o o �^ w�� o c c o^ -'O °n 2,0� �.
� o �9 m x r-•�� o< o �c��m'fl,:c
— _ > > a- o �:-v� 0 3,0 7 i:
W �'. �`: w o.3 c.�a c o c�<'�A ' o �N� c c�.� c a G'
\ �N O ' O N ` ��.
Q v 'O % O.C.A O� A.O r�.v, .�V,�'.�'J—� O � � -� O -C. O � i� r'
� ry C'� � ° p»°.o f ��'o°.° � � �h v.'_o` ° N,� �3 �'.,
� a.. - ° � � ^ g � ,•••'
(t7 O � 3 � N 1� O � �N 1 �^ ....? �. N �' � C �T-�i � C.�'� f: i...
� O ...O CL p'O N � n '.y O v % ld(�N 9 O ' l'.."� :; r'1
3 � l�9 4 a�O.C 7 O-�P) ."� � j p � p f, O .D n'J
�� � � 4'• N ."..,`� +� 4r O C '0 -� � y 0 �) � � p �
� (D , ?N � � y, m'C�y�� p t p�'� l� Cf A O V ...3 ,�O r ,C)
7 co cro �.� � -t o .^ � c � �� --u - M^ o n o 'L
tt � m' T j O D � � � � O ,j O'� n Q C n '
'� t1'.0 O �5 ij N n � j'C C O l� 1 O � � C. C1 �j r,nj
, U � fd ti :a n 7 n� �i O �!. '� y� ' 4,N'n � 7 7,
ea c � Q n ,.,�-, �..
. . •m °.�'�' �^ o-° !�. ^ ° �.C' ° '� ii � �•3 ,t .,`�;
�O..p o � � �� �i... � N � c�y n w �v q `t. u,h
O
' N O n � ?� �� J e; 7 •?� �4�:. O � C - , �v� ,.
�3 � n � O �..Q Gl C , � (T V :� �'3 N �
� C. n � T C
O w Q � ~ C.� � T n T1 U '� N ,,�, fo / �
'� n ^' 4 O^ N �✓ O r = � � / / ��
O � � G. ' �
?> > G
(9 � l:� � f
C.Tp O ?
. C,� ' '��i
. i
�.
/�.
' //���